Health and Maternity Project

The maternity project seeks to develop the coordination of services in response to domestic violence during pregnancy.

The Royal College of Midwives believes that domestic abuse is best challenged by a multidisciplinary and multi-agency approach, in which professionals work in partnership with local service providers, police, voluntary sector and the woman herself (RCM, 2006)

Who is affected?

• 30% of domestic violence starts in pregnancy*

• 1 in 6 pregnant women has suffered domestic violence**

• It has been argued that there are more foetal deaths as a result of violence than because of gestational diabetes or pre-eclampsia***

• The prevalence of domestic violence in pregnant women is much more common than many other pregnancy complication.

What are the impacts of domestic violence on women’s reproductive health?

Signs and symptoms can include:

• Rape and sexual assault

• Gynaecological injuries

• Injuries that are untended and of several different ages, especially to the head, neck, breasts, abdomen and genitals

• Unplanned or unwanted pregnancy

• Coping mechanisms such as smoking, alcohol and drug abuse, misuse of prescribed drugs.

What are the impacts of domestic violence on pregnancy?

Signs and symptoms can include:

• Repeated miscarriage

• Termination of pregnancy

• Antepartum haemorrhage

• Premature rupture of membranes

• Intra-uterine growth retardation

• Premature labour

• Abruptio placenta

• Stillbirth

• Low birth weight infants

• Fractures to the fetus

• Ruptured uterus, liver or spleen.

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What do survivors want?

• Routine enquiry about domestic violence in maternity settings is accepted by women****

• Disclosures of violence require privacy, confidentiality and sensitive questioning by non-judgmental staff.  Women may not disclose violence unless asked directly†

•  ‘I wish I’d been asked about what happened. I was so ashamed, but I really wanted to tell them. They didn’t ask me and I didn’t have the courage to tell them myself…They just gave me some painkillers and sent me home’‡

• Often women do not understand the failure of health professionals to ask in depth about the cause of their injuries or health problems§.

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What is the role of the healthcare professional/midwife?

The following excerpts illustrate the practice guidance that is available from a range of health institutions:

Royal College of Midwives, 2006

• The midwife is ideally placed to identify ongoing abuse and to offer care, support and information to women.  However, this contribution is often hampered by poor coordination of services, by inadequate knowledge of domestic abuse and its complexities and by midwives’ own experiences, beliefs and attitudes concerning domestic abuse.

• The RCM supports routine enquiry into domestic abuse throughout pregnancy and the postnatal period, which is accompanied by a package of measures that includes a systematic and structured framework for referral and support for women who disclose domestic abuse.

NICE, 2001

• All women should be routinely asked about domestic violence as part of their social history.

• Women should have the opportunity to discuss their pregnancy with a midwife in privacy, without their partner present, at least once in the antenatal period.

NICE Antenatal Care Guideline, 2008

• Healthcare professionals need to be alert to symptoms or signs of domestic violence, and women should be given the opportunity to disclose domestic violence in an environment in which they feel secure.

NICE Pregnancy and Complex Social Factors, 2010

• Women who experience domestic abuse should be supported in their use of antenatal care services by:

 - Training healthcare professionals in the identification and care of women who experience domestic violence

 - Making available information and support tailored to women who experience or are suspected to be experiencing domestic violence

 - Providing a more flexible series of appointments if needed

 - Addressing women’s fears about the involvement of Children’s Services by providing information tailored to their needs.

Centre for Maternal and Child Enquiries, 2011

• Continuing recommendation that routine enquiry, ‘asking the question’, should be made about domestic violence, either when taking a social history at booking or at another opportune point during a woman’s antenatal period.  Midwives should give high priority to ‘asking the question’ and to giving information to all women about domestic violence.

• All women should be seen alone at least once during the antenatal period to facilitate disclosure of domestic violence.

Although there is guidance for healthcare professionals/midwives to assume a role in the detection and management of domestic violence, the complexity of the issue can create barriers to this happening consistently, effectively and safely in practice.

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Barriers to midwives asking about domestic violence

• Fear of taking the lid off something which will get out of control

• Fear of not knowing what to do next

• Fear of causing offence

• Belief that it is not the province of the NHS

• Personal identification with abuse either as a victim or perpetrator ^.

Barriers to survivors disclosing domestic violence

• Fear of an unsympathetic response

• Fear of reprisals and serious escalation of violence from their partner if they get outsiders involved

• Shame and embarrassment over what has happened to them

• Fear that children will be taken into care

• Lack of awareness that help might be obtained from health professionals

• Fear of police or other authorities being contacted and – for some black and minority ethnic women – fear of deportation^.

Purpose of the Project

In January 2011, funded by the BIG Lottery, Standing Together and Imperial College Healthcare NHS Trust began collaborating on the Maternity Project.  The partnership seeks to bring together the expertise of survivors, healthcare professionals, specialist domestic violence advocacy services and other statutory and voluntary sector organisations in order to develop a survivor-centred approach to practice around domestic violence within antenatal services.

The project will span 5 years and primarily seeks to facilitate the implementation of routine antenatal enquiry (see Fig. 1).  Through ‘asking the question’, midwives will create opportunities for survivors to disclose their experiences, receive both information on their rights and choices, and be offered help from specialist support services.  As a result, survivors engaging with the project will be safer from domestic violence and both mother and baby will have a better chance of a happier and healthier life.

In order to safely and consistently implement and maintain routine enquiry, midwives must be adequately supported to undertake this within their role.  We aim to achieve this and overcome the barriers to ‘asking’ and ‘disclosing’ through:

• Establishing clear referral pathways to specialist IDVA services

• Developing and producing accessible information resources, to be available at antenatal clinics and to those women receiving community-based antenatal care

• Offering a programme of domestic violence education and training

• Offering regular professional updates on domestic violence.

All of these elements of the project will be informed and developed through on-going consultation with survivors.  We will identify the particular needs of women from Black, Asian, minority ethnic and refugee communities through this method and also by building partnerships with voluntary sector organisations that provide services for women from these communities.

Fig. 1: Diagram to show the Primary Components of the STADV: Health and Maternity Project (click on diagram to enlarge)

Footnotes:

* Lewis, Gwynneth, Drife, James, et al. (2001) Why mothers die: Report from the confidential enquiries into maternal deaths in the UK 1997-9; commissioned by Department of Health from RCOG and NICE (London: RCOG Press); also Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom (CEMACH)

**www.rcog.org.uk/news/one-six-pregnant-women-has-suffered-domestic-violence

***www.babycentre.co.uk/baby/youafterthebirth/sexandrelationships/domesticviolence/#10  

**** Price, Sally (2004) "Routine questioning about domestic violence in maternity settings" in Midwives Vol.7, no.4 April 2004

† Bewley S, Friend J and Mezey G. (1997) Violence against women. London, RCOG Press

‡ Langley H (1997) 'An overview.' In: Bewley S. Friend J, Mezey G (eds). Violence against women. RCOG Press, London. pages 147-8

§ Davidson, L. King, V. Garcia, J. Marchant, S. (2000) Reducing Domestic Violence - What Works? Health services. Policing and Reducing Crime. Briefing Note. London. Home Office 

^ Domestic Violence: A Resource Manual for Health Care Professionals, 2000 

For more information about the Helath and Maternity project please contact Jessica Donnellan.

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Last Modified: 1st July 2011